HIV: Why Nigeria’s plan to eliminate infant transmission may fail
By: Chioma Umeha
It was 7.00am, when my phone rang. I picked the phone without checking the caller. Peace is dead! Peace is dead! So I heard, but the voice could not be mistaken. It was that of Adanne (surname withheld) my cousin. As she sobbed profusely, I also heard noise at the background, perhaps neighbours trying to console her. ‘Its okay, I’m coming tomorrow,’ I told Ada as we fondly called her. My plea through the phone conversation appeared to have fallen on deaf ears. This made me more confused. So, I quickly rushed to Owerri, Imo state, her residence the next day.
I was apparently bewildered at the story that later unfolded. Adanne, aged 30, happily tied the nuptial knot December 5, 2009, to her heartthrob, Emeka. I was at her wedding. She was further overjoyed to become pregnant few months after. But her joy was punctuated a month after delivery, as her baby, Peace, often appeared sickly. Mistaken the symptoms to be for cold, the nearest health centre provided appropriate treatment. Peace appearance remained sickly, even as symptoms persisted. Three months later, she was admitted in the General hospital for thorough examination. A comprehensive diagnosis in the hospital’s laboratory eventually showed that Peace was HIV positive. Her HIV status led to further developments. The couple were forced to do HIV test to know their status. Adanne was HIV positive, while her husband was negative. Since there was no access to Antiretrovirals (ARVs) therapy treatment, the baby succumbed to AIDS and died at six months. Adanne is simply an example of hundreds of Nigerian women who transmit HIV virus to their babies unknowingly before birth.
That is why HIV test is compulsory for expectant mothers. Diana’s story is not completely different. This is because she refused to pass through the compulsory HIV test among other tests before pregnancy based on religious reasons. She said: “It is a sign of unbelief and sin against God to undergo HIV test.” However, her baby became ill two weeks after delivery. The sick baby was diagnosed of low blood. Diana who has the same genotype and blood group as her baby was asked to donate for her baby. Her blood sample which was tested prior to transfusion on her baby showed HIV positive. Her baby also tested HIV positive, though her husband was HIV negative. The hospital did not have Antiretrovirals (ARVs) therapy treatment for her baby, so she died three months later. Globally, almost 3.4 million children are already living with HIV. Only 23 per cent of them have access to treatment, while 51 per cent of adults do. Statistics also show that no fewer than 1.5 million children are orphaned yearly by HIV in the country.
Executive Director of the National Primary Healthcare Development Agency, NPHDA, Dr. Ado Mohammad, told journalists recently, at a week-long Integrated Service Delivery Training for community health workers, organized by the Programme for HIV/AIDS Integration and Decentralization ( PHAID) in Makurdi. Dr. Mohammad said: “HIV/AIDS continues to be a major burden in our country, with well over 1.5million children orphaned annually by the virus which also claims over 300,000 Nigerian lives yearly. “The devastation and dangers posed by the virus in our country calls for concerted effort by all Nigerians, including health workers, to ensure that we drive down the incidence of HIV/AIDS in Nigeria.” There are fears that the target of the ‘Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive’ will not be met.
Over two years ago, World leaders gathered in New York in June for the 2011 United Nations High Level Meeting on AIDS. At the meeting they launched the ‘Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive.’ The meeting provided a platform for a country-led movement towards the elimination of new HIV infections among children and keeping their mothers alive. The Global Plan was developed through a consultative process by a high level Global Task Team convened by UNAIDS and co-chaired by UNAIDS Executive Director Michel Sidibé and United States Global AIDS Coordinator Ambassador Eric Goosby. It brought together 25 countries and 30 civil society, private sector, networks of people living with HIV and international organizations to chart a roadmap to achieve the goal of the Global Plan by 2015. The goal of the Global Plan is to move towards eliminating new HIV infections among children and keep their mothers alive. One of the two ‘Global Targets’ in the plan is to reduce the number of new childhood HIV infections by 90 per cent.
Recent reports confirmed that childhood HIV infection rates are still high. Barely two and half years to the deadline ‘A progress report on the Global Plan’ said: “It remains an urgent imperative to reach all of these children with life-saving treatment.” Concerned about the situation, the report recently declared a state of public health emergency to save lives of children. The report titled “The 2013 Progress Report on the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive,” noted that Nigeria is on top of the list of countries where HIV infection is dropping slowly. “The world’s most populous black country lags behind five other African countries – Lesotho, Democratic Republic of the Congo, Cote d’Ivoire, Chad and Angola – all classified as countries with slow declining HIV infection rates,” the report said.
The UN said it was worried about the prevalence rate of HIV among Nigerian children. The global body warned that if Nigeria does not sit up in curbing HIV in children, the global target, part of the Millennium Development Goals, MDGs, will not be realised by 2015. “Without urgent action in Nigeria, the global target for 2015 is unlikely to be reached,” the report stated. Also, while Nigeria witnessed stagnancy, since 2009, in the prevalence of HIV among children, several other Sub Saharan African countries, witnessed a massive reduction in the prevalence rate of the condition. For instance is Botswana, which had the most rapid decline of HIV infection. This was followed by Ethiopia, Ghana, Malawi, Namibia, South Africa, and Zambia, which all witnessed 50 per cent decline in new HIV infections in children. Two more countries- the United Republic of Tanzania and Zimbabwe- are very close to achieving this target; prompting the UN to warn Nigeria to sit up in the fight against HIV in children.
Nigeria’s comparatively poor performance in reducing HIV transmission among children also reflected among the 21 countries under the Global Plan watch of the UN, according to the report. “Nigeria accounts for one third of all new HIV infections among children in the 21 priority countries in sub-Saharan Africa: the largest number of any country. Progress here is therefore critical to eliminating new HIV infections among children globally.” The report further said that the number of HIV infections among children aged between 0 and 14 and women aged from 18 to 49 is dropping very slowly in Nigeria. Giving the breakdown from a data sourced from the World Health Organisation (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Bank, the report stated that childhood HIV infection rates dropped by just eight per cent from 65,000 in 2009 to 60,000 in 2012. Further, only one in 10 or 12 per cent (260,000) of children with the condition were entitled to antiretroviral therapy in 2012, compared to eight per cent in 2009. Since three years, the number of children that have assessed antiretroviral therapy increased by only four per cent. Data from the report also showed that the number of women of child-bearing age (from age 15 to 49) acquiring HIV infection has not changed substantially since 2009.
The number dropped marginally in four years from 120,000 to 110,000. Worse still, only 20 percent of pregnant women living with the condition are receiving antiretroviral medicines to prevent mother-to-child transmission of HIV The report noted: “nearly all indicators assessed show stagnation and suggest that Nigeria is facing significant hurdles. It added: “the 21 countries (those under the Global Plan watch) had 210,000 newly infected children in 2012. This represents a reduction of 130,000 new infections annually or 38 per cent drop from 2009 when these countries had 340,000 new HIV infections among children”. However, it is cheering to note that the report commended efforts by the Nigerian government in checking the spread of the disease.
For instance, the country has already taken a bold step to focus on the 12+1 states with the highest burden of HIV, which account for about 70 per cent of new HIV infections. To achieve the elimination of new infections in children with equity, the global plan recognises that there is need to focus on 22 countries where 88 per cent of the world’s pregnant women live with HIV. The same countries are also home to approximately 90 per cent of children under 15 years of age in need of antiretroviral therapy. The next, is provision of support to countries with low prevalence and concentrated epidemics to reach women and children less likely to access PMTCT services due to geography, wealth and stigma and discrimination. It further suggested provision of high quality treatment for all infants, children and adolescents living with HIV to address the current global inequity in treatment access relative to adults.
Experts emphasise that new drugs and laboratory technologies that will enable simplified treatment to be provided are critical to decentralizing treatment to mother-child health clinics in remote and underserved areas. But, available records show that efforts to ensure availability of new drugs and laboratory technologies have remained a mirage in Nigeria. Prevention of Mother-To-Child Transmission of HIV (PMTCT) is an intervention that provides drugs, counselling and psychological support to help mothers safeguard their infants against HIV. Over 90 per cent of infections in children are acquired through MTCT. MTCT is the term used for vertical transmission of HIV from an infected mother to her newborn. With over 60 per cent of adults living with HIV being women, the number of infected children has been growing. This, experts say, occur during pregnancy, labour and delivery or during breast-feeding.
In the absence of interventions, the risk of such transmission is worse- 45 per cent. A member on the National Task Team on PMTCT, Emmanuel Enabulele, recently said in an interview that MTCT is fast becoming a burden in Nigeria compared to the rest of the world due to high prevalence of HIV in women of reproductive age and high total fertility rate. Enabulele further attributed the high prevalence of MTCT to characteristically prolonged breastfeeding culture, stigmatization by healthcare givers and poor access to PMTCT interventions as a result of the Federal Government not living up to its promises among others. Enabulele stressed the need for the Nigerian government at all levels to increase funding and strengthen capacity building, improving co-ordination and integral Maternal, Newborn and Child Health (MNCH) programmes.
Nigeria launched PMTCT scale-up plan in 2010 to reduce the PMTCT burden. However, experts have expressed fears that Nigeria may not meet the 2015 target for PMTCT. The national PMTCT Programme goal is to contribute to improved maternal health and child survival through accelerated provision of comprehensive PMTCT services. Specifically, the national PMTCT scale-up plan is to provide access to at least 90 per cent of all pregnant women to quality HIV counselling and testing by 2015. Also, it is expected to provide more efficacious ARV prophylaxis to at least 90 per cent of HIV positive pregnant women and HIV exposed infants by 2015. Prophylaxis is the prevention of, or protection against disease. For instance, if women are routinely given anti-malarial tablets in pregnancy to prevent, rather than treat, malaria, it is called malaria prophylaxis. It is also supposed to ensure that at least 90 per cent of pregnant women requiring ART for their own health receive life-long ART. Antiretrovirals (ARVs) are drugs that fight the HIV virus. ARV therapy, otherwise known as ART can help people with HIV stay healthy.
Short courses of treatment (using a single drug, known as monotherapy) can be given to women in the late stage of pregnancy and/or during labour and delivery, in order to reduce the risk of passing HIV to the baby. Sometimes drugs are also given to the baby in the first week of life. This short course treatment will not be of any benefit to the mother’s own health, but will not harm it. Commenting on the case of Adanne and Diana, Dr. Dan Onwujekwe, Chief Research Fellow, Clinical Sciences Division, Nigeria Institute of Medical Research (NIMR) explained that their babies would not have been infected by the virus if they passed through the compulsory HIV test to know their status and placed on ARV therapy. Onwujekwe who spoke in an interview, further insisted that both mothers and their babies would not have had any health complications if they were placed on ARV therapy that can help people with HIV stay healthy. He noted: “the short courses of treatment (using a single drug, known as monotherapy) can be given to women in the late stage of pregnancy and/or during labour and delivery, in order to reduce the risk of passing HIV to the baby.” The rest of the details of the national PMTCT scale-up plan include; provision of quality infant feeding counseling HIV positive pregnant women and early infant diagnosis services to HIV exposed infants by 2015.
Experts have lamented that actualisation of the national PMTCT scale-up plan may end as a fantasy in view of seemingly insurmountable obstacles. First, the PMTCT programme coverage is still very limited in Nigeria. Available data shows that less than 10 per cent of antenatal facilities offer PMTCT services, just as there are indications that the country’s plan in scaling up PMTCT programmes to reach every pregnant woman and baby across might be far-fetched. Corroborating earlier views, Dr Oliver Ezechi, of the Clinical Sciences Division, Nigerian Institute of Medical Research, Yaba Lagos, in an interview bemoaned that PMTCT coverage still remains low with only 1,120,178 (16.9 per cent) pregnant women counselled, tested for HIV and received their results in 2011. Ezechi also said that 17.6 per cent of the HIV-infected pregnant women in 2011 received antiretroviral. This is even as integration of HIV care, treatment and support for women found to be positive and their families is still a far-cry based on current trends.
Ezechi, who is also a gynaecologist, underscored the importance of care and support of people infected and affected by HIV/AIDS including; Orphans and Vulnerable Children (OVC). According to him, the target is to create an enabling environment for the legal protection of OVC by 2015 The Clinical Researcher identified two major challenges of achieving national PMTCT plans to include fear and stigma. His said: “Fear drives the epidemic underground’ adding, ‘delay in seeking care, increased transmission, non-adherence to treatment and non-disclosure are major challenges.” Referring to Nelson Mandela’s statement at the X1V International AIDS Conference 2002, Ezechi said: “Stigma, discrimination and ostracism are the real killers.” He further observed that it is for these listed reasons and more that the likes of Adanne and Diana decline from undergoing HIV test, while others will not want to divulge their status.
Also, in her paper titled: Update on Elimination of Mother to Child Transmission of HIV (eMTCT) Nigeria, Dr. Chukwuma Anyaike, Deputy Director, Prevention, HIV/AIDS Division, Federal Ministry of Health (FMOH) confirmed that 50 per cent of new infections are in children with 90 per cent arising from mother-to-child transmission. Anyaike also lamented the eMTCT is facing challenges. She identified some of the challenges to include weak monitoring and evaluation system and referral system and poor retention of clients; political commitment and funding at state and local government area (LGA) level among others issues.
This story was published in Newswatch Times on October 10, 2013.
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